Integrated Care Coach

humana; Orlando (FL); Hybrid; USD 52,000 - 78,000; Full time

Job summary

Humana seeks a patient-centered caregiver to conduct structured interviews, perform home visits, and identify barriers to care. You will coordinate with primary care teams and community resources to support high-risk or geriatric patients.

The role requires delivering culturally competent education on chronic disease management, managing transitions from hospital/ED, and engaging patients through community programs. Travel to patients' homes and clinics is involved.

Qualifications

• Healthcare professional with ambulatory/primary care or senior-care experience with direct patient care.
• Ability to discuss chronic conditions and reinforce medication instructions.
• Comfortable with regular home visits and community outreach.
• Experience in patient education, care coordination, and social support for high‑risk/geriatric populations.

Responsibilities

• Conduct structured patient interviews and document findings for providers.
• Perform home visits to assess living conditions and barriers to engagement.
• Identify social barriers and connect patients with community resources.
• Deliver chronic disease education using approved materials.
• Coordinate care between patients, PCPs, specialists, pharmacies, home health, and community providers.
• Follow up after hospitalizations/ED visits to support safe transitions.

Skills

Home visits

Care coordination

Patient education

Chronic disease management

Cultural competence

Bilingual English/Spanish

Communication skills

Education

LPN/LVN license or MA certification

Active unrestricted license/credential

RN license (preferred)

Job description

Become a part of our caring community

Duties and Responsibilities

• Clinical Screening & Escalation: Conduct structured patient interviews and collect health-related information (e.g. medication regimen and barriers to adherence, social barriers, functional status.) Document and share findings with providers.
• Outreach and Home Visits: Perform home visits to observe living conditions, identify safety concerns, and review environmental or social factors impacting engagement.
• Social Needs support: Identify barriers to care, address immediate social stressors, and connect patients with appropriate community-based resources.
• Chronic Disease Education: Deliver culturally appropriate education using approved materials to reinforce provider and pharmacist recommendations for chronic disease management.
• Care Coordination: Serve as a liaison between patients, primary care, specialists, pharmacies, home health, and community providers. Support care transitions, coordinate follow-up, and facilitate communication across care settings to close care gaps. Partner closely with the primary care provider to create care plans and priority action items.
• Post‑Hospital and Emergency Department Follow‑Up : Conduct timely follow-up after hospitalizations and emergency department visits to support safe transitions. Review discharge instructions, schedule/confirm follow-up appointments, verify patient reported medications and elevate discrepancies to providers.
• Community Engagement: Encourage and support patient connection to community-based programs that reinforce health goals, including initial engagement when appropriate.
• Cultural Competence: Deliver patient centered, culturally sensitive care that respects patients' beliefs, preferences, and social context.
• Develop a holistic understanding of patient needs via a 5Ms framework (What M atters Most, M ind (Mentation), M obility, M edications, M ulti-complexity) and identify barriers impacting health outcomes.
• Prepare, participate and discuss patients during High-Risk Rounds

Use your skills to make an impact

This role has a mobile presence, involving travel to patients' homes, healthcare facilities, community-based settings, and assigned clinics.

Workstyle: Combination of clinic-based and field work

Location: Must reside in designated market area

Hours: Monday-Friday, 8:00 AM-5:00 PM; overtime may be required

TB Statement:

This role is considered patient facing and is part of Humana's Tuberculosis (TB) screening program. If selected for this role, you will be required to be screened for TB.

Driving Statement:

This role is part of Humana's driver safety program and therefore requires an individual to have a valid state driver's license and are expected to maintain personal vehicle liability insurance. Individual must carry vehicle insurance in accordance with their residing state minimum required limits, or $25,000 bodily injury per person/$25,000 bodily injury per event /$10,000 for property damage or whichever is higher.

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Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, know

Required Qualifications

• Healthcare professional with 3+ years of Ambulatory, Primary Care, or Senior‑Care experience with direct patient care
• Ability to discuss chronic conditions and reinforce medication instructions
• Comfortability to regularly conduct home visits and community-based outreach
• Demonstrated experience in patient education, care coordination, and social support of high-risk or geriatric populations

Preferred Qualifications

• Active Unrestricted LPN/LVN license or MA Certification
• Licensed or Unlicensed Medical professional with equivalent foreign Registered Nurse (RN) or Physician license
• Experience in care coordination, case management, population health and/or value-based care models
• Experience conducting post-hospital/ED follow up with appropriate escalation
• Familiarity with Medicaid, Long-term Care, and HCBS programs
• Experience working with seniors and medically complex populations
• Prior home visit experience and knowledge of field safety practices
• Bilingual in English and Spanish with the ability to read/write/speak in both languages